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Full text of "United States Navy Medical News Letter Vol. 33 No. 11, 5 June 1959"

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NavMed 369 


Rear Admiral Bartholomew W, Hogan MC USN - SurgeonGeneral 
Captain Leslie B. Marshall MC USN (RET) Editor 

Vol. 33 Friday, 5 Jtine 1959 No. 11 

I ■■ . M . I .- -. ■ — ■ . 


Historical Fund of the Navy Medical Department 2 

Navy Tissue Bank 3 

Venereal Diseases Today 6 

Percutaneous Renal Biopsy 11 

Management of the Bladder in Traumatic Paraplegia 14 

Treatment of Parosteal Osteoma of Bone 16 

Digitalis Intoxication 19 

Staphylococcal Pneumonia - Clinical Evaluation of Forty Cases 21 

Letter to the Surgeon General , 22 

Medical Symposiums foir Fiscal Year I960 23 

Environmental Sanitation Courses for Medical Service Warrant Officers 23 

Medical Intelligence Reports , 24 


From the Note Book , 24 


Dental Officer Strength Down - Dental Procedures Up 26 

Nonadherence to Repair Contract 26 


Medical Department Correspondence Courses 27 


Common Errors in the Diagnosis of Plumbism 30 

Evaluation of Blood Lead Analyses 31 

Cadmium Poisoning 33 

Heat Stress in Tropical Climates 35 

Medical News Letter, Vol. 33, No. 11 

of the 

A committee has been formed with representation, from the Medical 
Corps, Dental Corps, Medical Service Corps, Nurse Corps, and 
Hospital Corps for the purpose of creating a fund to be used for the 
collection and nnaintenance of items of historical interest to the Medical 
Department. Such items will include, but will not be limited to, por- 
traits, memorials, etc. , designed to perpetuate the memory of dis- 
tinguished members of the Navy Medical Department. These memorials 
will be displayed in the Bureau of Medicine and Surgery and at the 
National Naval Medical Center. Medical Department officers, active 
and inactive, are invited to make small contributions to the fund. It is 
emphasized that all donations must be on a strictly voluntary basis. 
Funds received will be deposited in a Washington, D, C. b'ank to the 
credit of the Navy Medical Department Historical Fund, and will be 
expended only as approved by the Committee or its successor and for 
the objectives stated. 

It is anticipated that an historical consmittee will be organized at each 
of our medical activities. If you desire to contribute, please do so 
through your local historical committee or send your check direct, 
payable to Navy Medical Department Historical Fund, and mail to: 

Treasurer, N. M. D. Historical Fund 
Bureau of Medicine and Surgery (Code 14) 
Department of the Navy 
Washington 25, D. C. 


F. P. GILMORE, Rear Admiral (MC) USN, Chairman 
C. W. SCHANTZ, Rear Admiral (DC) USN 
L, J, ELSASSER, Captain (MSC) USN 
R. A. HOUGHTON, Captain (NC) USN 
T. J. HICKEY, Secretary- Treasurer 


Medical News Letter, Vol. 33, No. 11 

The Navy Tissue Bank 

Physical trauma creates a tremendous demand for the replacement of 
destroyed tissues. Grafting of tissue — bone or skin — is not a new procedure. 
It has been done with varying degrees of success since the seventeenth cen- 
tury. Heterografts — removal of tissue from one species and transplanting 
it to another — probably were the first kind of grafts to be used. Autograft — 
tissue removed from one site on a patient's body and grafted to another — is, 
when clinically feasible, the n^ethod of choice. Nowadays, the homograft, 
that is, removing tissue from one individual for subsequent grafting to 
another, is frequently used. 

Homografts are used to replace a tissue whose function is decreased 
by either disease or trauma. Some specific uses of the homografts are: 
arteries for aneurysms, bone for fusions, cartilage for rhinoplasties, dura 
for dural defects, fascia for defects of the chest wall, and skin for the treat- 
ment of burns. 

Many surgeons believe that the physiologic price that the patient pays 
for an autograft is entirely too expensive when the homograft accomplishes 
a comparable, although not identical, return at less physiologic cost. This 
is especially true when the surgical risk is tremendously increased if the 
patient is a child or an elderly person. This makes it imperative to develop 
methods to procure, process, bank, and dispense homografts for clinical 
use and for research. 

In 1949, the Navy Tissue Bank was started at the Naval Medical School, 
National Naval Medical Center in Bethesda, Md. This was the first tissue 
bank where various types of tissues were procured, processed, banked, dis- 
pensed, and clinically evaluated as homografts. In the past 10 years, per- 
sonnel assigned to the tissue bemk have continued to study and improve 
methods of preserving various types of grafts and to evaluate the success 
of their use. 

The principal source of tissue is a recently deceased person on whom 
a sterile postmortenn procedure is performed. Specific criteria must be 
observed in the selection of a donor. There must be no evidence of malign 
nancy or transmissible disease, and the body must be received within Z4 
hours after death. Legal permission must be granted by the next of kin 
following the death of the patient. When these criteria are fulfilled, an 
officer from the tissue bank talks with the family, explains the procedure 
and the uses for homografts, and requests permission to excise certain 
tissues. No patient is ever asked for tissue donation. 

The initial processing of tissue for preservation is started immediately 
after removal. All homografts are cultured for aerobic and anaerobic con- 
taminants before they are deposited in the Tissue Bank. 

For the initial processing of all tissues except cartilage and skin 
(unless freeze -dried), 85% Kinger's solution is used to which is'added 500 
thousand units of aqueous penicillin G and 0.5 gm. of streptomycin per liter. 

Medical News Letter, Vol. 33, No. 11 


Skin. Split -thickness skin is placed in a nutrient medium of balanced 
saline solution with 10% pooled human serum, 500 thousand units of aqueous 
penicillin G, and 0. 5 gm. of streptomycin per liter. Phenol red is added to 
indicate pH range. If the phenol red indicates pH change, up to 50% of the 
medium may be replaced with fresh medium. 

Skin is also treated by the glycerol -Ringer method. It is placed in a 
beaker containing 15% glycerol, 85% Ringer's solution, 500 thousand units 
of aqueous penicillin G, and 0. 5 gm. of streptomycin per liter. After an 
hour in this solution, the skin is ready for further processing. Perforated 
cellophane is soaked in the solution and squeezed dry. An arbitrary length 
of cellophane is then laid down on a sterile surface and segments of the im- 
pregnated skin are smoothed on top of the cellophane. Another layer of 
cellophane is placed on top of the skin and more skin is smoothed upon it. 
This process is continued until approximately 500 square centinaeters of 
skin are so placed. This constitutes one homograft deposit. The deposit is 
put in a Pyrex test tube. The tube is immersed in 95% ethanol-carbon dio- 
xide slush at minus 76 C.-for 15 minutes for rapid freezing. Utmost pre- 
caution must be taken that none of the carbon dioxide slush comes in contact 
with the homograft. After freezing, the grafts are stored in a dry ice chest. 

If the skin is to be freeze-dried, it is rinsed in Ringer's solution con- 
taining the same amounts of antibiotics as previously mentioned. After rapid 
freezing, deposits are put in one sterile wrapper and stored at minus 76° C. 

Fascia lata. Following excision, fascia lata is rinsed in the solution 
and then pinned on a Teflon covered board. All extraneous soft tissue is re- 
naoved by dissection. When this is acconnplished, the tissue is measured, 
placed in a Pyrex test tube, cultured, and rapidly frozen in the same manner 
as skin. The tubes are wrapped in sterile double muslin covers ajid stored 
in. dry ice at minus 76** C. to await further processing. 

Arteries . After rinsing in balanced saline solution, these homografts 
are dissected free of any remaining connective tissue. The vessels are 
measured, exact drawings made of each artery, cultures are taken, and the 
vessels are placed in a sterile glass jar filled with nutrient medium. They 
are stored at 4° C. to await culture reports. If the bacteriologic reports 
are negative, each homiograft is then placed in a Pyrex test tube and rapidly 
frozen. These tubes are also wrapped in sterile double muslin before storing 
in dry ice. If an artery is contaminated, it is sterilized in ethylene oxide or 
beta propiolactone. 

Dura Mater. The dura is rinsed in the Ringer's solution containing the 
antibiotics. It is then measured, cultured, placed in a Pyrex tsst tube, 
rapidly frozen, and processed in the same manner as fascia lata. 

Cartilage . The costochondral cartilage is scraped free of soft tissue, 
cultured, and soaked in an aqueous solution of stainless merthiolate 1 to 1000. 
It is recultured in 14 days. After this interval, it is ready for clinical use. Re- 
soaking and reculturing are not indicated unless the solution beconses turbid. 

Medical News Letter, Vol. 33» No. 11 

Bone. As each bone is removed, it is wrapped in a sterile towel and 
taken to the processing room. On a sterile draped table the soft tissue is 
removed. The long bones are cut into strips by use of a bone saw. The ilia 
are either sawed into dice-sized fragments, ground in a bone mill, or cut 
into cancellous strips. Kibs are cut into segments called "match sticks. " 
Each graft is cultured for aerobic and anaerobic contaminants. Culturing 
is done by swabbing the surfaces with saline moistened cotton-tipped applica- 
tors. Bacterial safety of the ground cancellous bone is determined by placing 
a fragment into the bacterial culture medium. 

The bone homografts are then washed in Ringer's solution with the added 
antibiotics. Each graft is then placed in a sterile bottle plugged with gauze. 
Each bottle is labeled with a numbered metal band, wrapped in sterile double 
muslin wrappers, and stored in a dry ice freezer. Culture reports are re- 
ceived in 4 days and those grafts reported as "No Growth" are then freeze- 

Freeze -drying is the removal of moisture from a frozen substance in 
a vacuum. At the Tissue Bank, a commercial freeze drier that has been mod- 
ified to serve the purpose is used. 

Before the process is started, the freeze drier is sterilized by spray- 
ing it with dichloran. Trichlorethylene circulates through the coils and is 
cooled by the ethanol and carbon dioxide slush in the external cooler. The 
cooled trichlorethylene then lowers the temperature of the upper shelf to 
minus 45° C. Using sterile techmque, the bottles of homografts are removed 
from the dry ice chest, quickly luiwrapped, ajid placed on the upper or the 
"Tissue Shelf. " The door gasket is coated with silicone lubricant and securely 
closed; the vacuum pump is turned on. Pressure maintained at 5 to 10 microns 
of mercury within the chamber is recorded by a gauge, and temperature by 
dial thermometer. 

The temperature of the upper shelf is allowed to rise gradually to 0° C. 
in 24 hours by closing the valve to the trichlorethylene, and to 30° C. on the 
fifth day to supply heat to remove tissue water. However, the temperature 
of the lower shelves remains at minus 45*^ C. to trap the water of sublima- 
tion. The soft tissue freeze drying cycle is 3 days; 14 days are required for 
bone and cartilage. 

The pressure in the chamber is gradually increased to atmospheric 
pressure. The deposits are removed using sterile technique and are vacuum 
packed by a small hand vacuum pump. The jars are sealed with sealing wax. 
The material is labeled and checked to be positive that all records, numbers, 
measurements, and deseriptions agree. The homografts are then "banked" 
at room temperature until they are needed. 

The storage time of the freeze-dried homograft is unknown. Tissues 
have been stored for 7 years and no changes have been observed in them 
either clinically or grossly. 

Medical News Letter, Vol. 33, No. 11 

Before most homografts can be used, they must be rehydrated. To 
rehydrate a freeze -dried tissue, the sealing wax is removed from the stop- 
per by chipping it off with a sharp instrument and the surface is then cleansed 
with ether which acts as a solvent for any remaining wax. The rubber stopper 
is then swabbed thoroughly with alcohol. Enough sterile isotonic saline to 
completely immerse the horhograft is injected through the rubber stopper. 
Rehydration is facilitated if the vacuum is maintained during injection. Approx- 
imately 30 minutes is required for rehydration of soft tissues; cortical bone 
and cartilage require from 24 to 48 hours to rehydrate. Cancellous bone and 
rib match sticks need not be rehydrated prior to use as these are readily re- 
hydrated by the recipient's fluids. Glycerol-Ringer frozen tissues are re- 
moved from the container, cultured, and then placed in 37° C. isotonic saline 
for about 20 nriinutes. 

After rehydration of the graft, the rubber stopper is removed irovn the 
bottle with a sterile clamp. The tissue is removed by a sterile instrument, 
and cultured for aerobic contaminants before it is used surgically. 

The nurse in the tissue bank is responsible for helping to teach corps - 
men to become tissue bank technicians. They must learn and understand all 
procedures relating to procuring, processing, banking, dispensing, andusing 
homografts. The nurses' s position is very similar to that of an operating 
room supervisor. When a surgeon wants a homograft, it is on hand ready to 
be dispensed. 

As studies and research continue, the nurse plays an active role in 
helping with the projects, collecting data, and keeping records, 
(L,T Sarah C. McGinniss NC USN, Naval Medical School, NNMC, Bethesda, 
Md. , The Navy Tissue Bank: American Journal of Nursing, 59: 666-669, 
May 1959) ~ 

Venereal Diseases Today 

The venereal diseases are so called because they are acquired and 
spread principally through sexual exposure. They are five in number and 
their frequency in the United States is in this descending order: gonorrhea, 
syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale. 
The last three have been classed as minor venereal diseases because their 
incidence and prevalence are considerably less than those of gonorrhea or 
syphilis. In Massachusetts, as well as in the other states, the minor ven- 
ereal diseases constitute only 0. 5 to 1% of the total cases reported. This 
article summarizes the present state of knowledge of the venereal diseases 
from the viewpoint of clinical and public health medicine. 

In the United States, there was a slow but steady increase in reported 
cases of gonorrhea and syphilis from 1920 to about 1935. In 1936, the 

Medical News Letter, Vol. 33, No. II 

prevalence of syphilis rose sharply and continued to rise during World War 11. 
This marked increase was due to two factors. The first was the impact of the 
depression on the family and a relaxation of popular sexual habits. The second 
and more important factor was the effect of the organized programs of syphilis - 
oriented venereal disease control in all state health departments. It is under- 
standable that with intensification of syphilis case finding, the morbidity rate 
for this disease climbed more sharply than that for gonorrhea. 

Beginning with fiscal year 1948, however, there was a significant de- 
cline in reported cases of syphilis among the civilian population. This drop 
persisted up to 1956 when the downward trend was reversed. In 1948, 338, 141 
cases of syphilis were reported, or 234. 7 per 100, 000 population, whereas at 
the end of 1955, a total of 122,075 reports of syphilis, or 76.0 per 100, 000 were 
received. This represents a rate decline of 68%. Yet in 1955, syphilis ranked 
fourth among the reportable infectious diseases, the top three being measles, 
gonorrhea, and the streptococcal infections, including scarlet fever. But in 
fiscal year 1956, infectious and total syphilis increased nationally for the first 
time in 9 years. In fiscal year 1957, cases of syphilis in all stages reported 
by state health departments increased by 5% above the previous year. In fiscal 
year 1958, infectious syphilis increased by 5. 9% over the previous year. It is 
interesting that in fiscal year 1951 not a single state showed an increase in 
primary and secondary syphilis over the previous year, but in the 7 successive 
years, 1952 through 1958, an increasing number of states showed an increase 
in infectious -lesion syphilis. During the past year, twenty-three states and 
the District of Colun:ibia reported an increase in infectious syphilis. 

Gonorrhea is the most undiagnosed and iinder reported of all the venereal 
diseases, if not of all the commvmicable diseases. Yet, in spite of this, it 
ranks second to measles among the reported communicable diseases in the 
United States. Beginning in 1920, gonorrhea showed a more or less stable 
rate each year until World War II, when for the first time it showed a signifi- 
cant increase which continued until 1948 when a gradual decline began. Thus, 
gonorrhea has declined much more slowly than syphilis and in the past 5 years 
has remained almost stationary. 

The venereal diseases are discovered and reported more frequently in 
males than in females, and in nonwhite than in white people. It is estimated 
that there are approximately 1, 250, 000 cases of syphilis in the United States 
that are in need of treatment, and approximately 1, 000, 000 fresh cases of 
gonorrhea each year. Gonorrhea is reported forty times as frequently for 
the nonwhite as for the white population. The ratio of males to females with 
gonorrhea is about 2. 5: 1 for both the white and the nonwhite population. 
Although there was a greater frequency of reported cases of syphilis among 
nonwhite s than among whites, the ratio was not as great as was seen with 
gonorrhea — 3 among the nonwhite for every 2 among the white population. 
Whereas, the incidence in nonwhite males and nonwhite females was about 
the same, white females were named as being infected with syphilis half as 

8 Medical News Letter, Vol. 33, No. 11 

frequently as white males. The variations between males and females and 
between whites and nonwhites have been attributed to a number of factors: 
One is the under -reporting of cases among whites and the more complete 
reporting among nonwhites because Negroes are more apt to go to public 
clinics. The disparity of rates between the sexes is probably due to the 
greater ease of diagnosis in males. 

The most significant observation is the increase in gonorrhea and 
infectious syphilis among the teen-age and young adult population during 
the past 6 years. More than 53% of the reported cases of gonorrhea and 
syphilis in 1957 were in the group of 15 to 24 years of age; yet this group 
comprises only about 13% of the total population. During 1957, Z2. 4% of 
the total reported cases of infectious venereal disease occurred among teen- 
agers. Last year, nearly half of the persons involved in venereal disease 
epidemics in the United States were teen-agers. The reported incidence of 
infectious venereal disease is highest among females at the age of 18 and 
among males at 23. 

During 1957 in Massachusetts, 61. 5% of patients with infectious ven- 
ereal disease were single, 22, 9% were married, and 15. 6% were widowed, 
divorced, or separated. Analysis of the educational status of the patients 
who came to the twenty-three state cooperating clinics revealed some inter- 
esting data: 75% had completed the eighth grade, 22% had finished high 
school, and 5% had gone beyond high school. 

Analysis of the sexual contacts of infectious patients in Massachusetts 
revealed that about 95% were reported by patients from the twenty-three 
clinics. Thus, any conclusions from these data would apply only to clinic 
patients and not to the infected patients of the state as a whole. For the year 
1957, it was found that 46.9% of the female sexual partners were pickups, 
32. 8 were friends, and 9. 6% were prostitutes. In 42. 4%, the infected men 
met these girls in a bar or tavern. Exposures took place in a home in 57. 6%, 
in a car in 18. 5%, and in a hotel room in 4. 0% of the cases. 

At the outset, it is important to realize that the venereal diseases con- 
not be eradicated by present control methods alone. Until new and better pro- 
cedures can be devised, all that clinical and public health medicine can ex- 
pect is a reduction of these diseases. How much they can be reduced depends 
directly upon the efficiency of practitioners in both groups. Modern venereal 
disease control programs are directed essentially at early diagnosis and treat- 
ment — that is, finding potential cases, establishing a diagnosis, and treating 
the infected person. There are three methods of finding these cases: selec- 
tive mass blood testing, public education, and interviewing and investigation 
of contacts. 

Selective mass blood testing is performed when certain segments of th«, 
population undergo a blood test — for example, persons in high-prevalence 
areas, those about to be married, pregnant women, blood donors, prospective 
draftees, hospital patients, and patients with skin diseases. Some hospitals 

Medical News Letter, Vol. 33, No. 11 

and physicians have stopped doing routine blood tests on new patients and 
hospital admissions and later are embarrassed to find that syphilis was the 
cause of the patient's symptoms or existed in addition to some other problem. 
Patients with symptomatic late syphilis almost invariably could have been 
discovered before this stage if the blood test had been maintained as a rou- 
tine laboratory procedure. 

Public education is aimed at motivating persons who have exposed them- 
selves to seek early medical care. People need to have accurate information 
that will be appropriate for their age and cultural status. They should know 
the early signs and symptoms and the manner in which these diseases are 
spread, where persons suspecting infection nnay go for examination, and what 
constitutes good modern treatment. 

Unfortunately, with the exception of the military population, very little 
popular education is carried out today, principally because of inadequate 
budgets and insufficient fxmds for hiring conapetent professional educators. 

Interviewing and investigation of contacts begin with the infected patient. 
By skill, tact, and persuasion, attempts are made to elicit the names of those 
to whom the patient was exposed during the tinne covered by the maximum 
incubation period as well as those whom the patient had exposed since the 
onset of the symptonns. Once this information has been obtained, the search for 
contacts begins; when found, they are examined and treated if infected. Some — 
particularly female contacts of patients with gonorrhea — are treated prophy- 
lactically because of the difficulty in diagnosing gonorrhea in the female. 
These techniques have obvious limitations and difficulties. Yet no others are 

Preventive methods offer little hope of eradication because sexual pro- 
miscuity is basic to the spread of these diseases. If promiscuity could be reduced 
or eliminated, the venereal diseases would show a corresponding decline or 
would disappear entirely. There is little to indicate at this time that the sexual 
habits of the population will undergo a radical change for the better. Purely 
mechanical, chemical, or antibiotic prophylaxis ^apart from its legal, moral, 
or social implications— is not particularly effective or useful and has been 
deemphasized, even by the Armed Forces. 

No method of producing artificial immunity against these diseases exists 
as with vaccination in smallpox or yellow fever. There is no way of attacking 
the organisms causing the diseases apart from treating the patient. There is 
no intern:! ediate host. The infectious reservoir lies in the group of missed and 
undiagnosed cases and treatment failures. 

With clinical and public health medicine well organized for early detec- 
tion and treatment and with penicillin so swift and effective, the case rates of 
syphilis and, to a lesser extent, those of gonorrhea underwent a rapid decline 
beginning in 1948 and continuing until 1956. In their enthusiasm, many phys- 
icians in clinical and public health medicine, who should have known better, 
proclaimed that gonorrhea and syphilis were defeated and no longer presented 

10 Medical News Letter, Vol. 33, No. II 

a problem. Unfortunately, the unprecedented gains led physicians to lose 
sight of how the gains were accomplished. Consequently, budgets of public 
health medicine for the control of venereal disease were slashed to the point 
where the program became ineffectual. Many state health departments rely- 
ing on Federal support either abandoned their programs when Federal funds 
were cut or assigned them to another and usually over-worked division. With- 
out adequate appropriations for finding syphilis, no cases were found. This 
led to the erroneous idea that none existed and that, therefore, there was no 
problem. The integrated team of clinic and public health medicine was broken 
and the predictable rise in venereal disease incidence occurred in 1956. 

Although public health medicine bears a responsibility for the rising 
rates of infectious syphilis, it shares it with the clinician because he too 
was lulled by premature optimism and complacency. 

The therapeutic efficiency of penicillin has lulled some physicians into 
mental laziness. In sonne cases, a patient with a positive blood test was 
treated vigorously without benefit of diagnosis, the idea being that "if the 
patient has syphilis he will be cured, and if he doesn't, the treatment won't 
do any harm. " Failure to diagnose, to take blood tests, and to think of 
syphilis in the differential diagnosis serves only to increase the reservoir 
in the community. 

Next is the problem of interviewing patients for contacts. It is known 
that for every infected patient there should be at least one infected contact, 
the source of infection. Yet, in 1958, patients with diagnosed primary and 
secondary syphilis interviewed for contacts had an epidemiologic index of 
0. 5, which means that for every 2 cases of lesion syphilis, only one infected 
contact was found. Thus, half the time, even the source of the patient's 
infection could not be determined, let alone the people whom the patient him- 
self had infected. How can syphilis be controlled when more than half the 
infected patients causing the disease are allowed to run around undetected in 
the community? Compounding this problem is the failure of private phys- 
icians to interview their patients for contacts. Understandably, the private 
physician is busy. He may not have tinfie to interview, or even to bring in, 
the contacts for examination. However, he can arrange to have his patient 
quietly and diplomatically interviewed by the skilled and trained personnel 
of the health department. 

Added to the problems of control is the population mobility so char- 
acteristic of the United States. In the course of a year, 4, 000,000 to 
5,000,000 people move from one state to another, and, roughly, an equal 
number within the state move from one county to another. Migrant laborers 
moving across vast sections of the country in search of seasonal agricultural 
work show consistently higher rates of infection than other segments of the 
population. No local surveillance mechanism can cope with a sudden epidemic 
covering a number of states. The rapidity with which the disease moves from 
area to area is indicated by a recent report that 9% of the contacts of civilian 

Medical News Letter, Vol. 33, No. 11 11 

patients and 36% of those of military patients resided outside the state in 
which they were exposed to the disease. 

Sexually promiscuous persons are notoriously restless, moving quick- 
ly from area to area. The ease and speed of modern travel make it neces- 
sary to think of venereal disease control activities on a national rather than 
a state or sector level. States with good i;ontrol programs are constantly 
being seeded from sister states with less adequate programs or no control 
programs at all. The problem in these less fortunate states is frequently 
that of money, a lack of which can be helped by the restoration of Federal 
assistance grants to the states for the benefit of all. 

Members of the medical profession, then, need to adjust themselves 
to the fact that, although the syphilologist may be dying out, syphilis is not. 
The words of Neisser are just as appropriate now as they were 50 years ago 
when arsphenamine was introduced: "Human indolence and stupidity will 
arrange that syphilis will never die out, but will remain always a dangerous 
disease. " (Fiumara, N. J. , et al. , Venereal Diseases Today: The New 
England J. Med., 260 : 863-868, April 23, 1959) 

Sjc sjc ^ 35; :iic ^ 

Percutaneous Kenal Biopsy 

Since the first practical method of renal biopsy by the percutaneous 
route was developed, at least 2000 cases have been recorded. Perhaps 
several times that number of biopsies have actually been performed. Al- 
though the percutaneous renal biopsy is well established as a research pro- 
cedure, it is not so well established as an ordinary diagnostic procedure. 
This review discusses the use of the percutaneous renal biopsy as a diag- 
nostic tool and the changes in concept of renal disease that have resulted 
from its use in investigation. 

As with all operative procedures, the percutaneous renal biopsy car- 
ries certain risks. Even though local conditions vary widely, a limited 
evaluation of the risk is feasible. In at least 3 institutions, a series of 500 
or more biopsies without mortality has been accumulated. In many other 
institutions, the percutaneous renal biopsy has been performed in 200 or 
more cases without mortality. On the other hand, several deaths have 
occurred on the first attempt or in a small series. It would appear that in 
experienced hands the risk of mortality should be less than 0. 1%. 

Morbidity has been experienced in almost every series. Hemorrhage 
of some degree probably occurs after every biopsy. In terminal or near 
terminal patients, an antemortem biopsy is accompanied by evidence of 
blood loss ranging from 10 to 50 ml. The local tissue forces in the region 
of the posterior aspect of the kidney seem capable of tamponade and control 
of this amount of bleeding. In most cases the only evidence of bleediiig_from 

12 Medical News Letter, Vol. 33, No. 11 

the biopsy site is the appearance of blood in the urine. Hematuria is usually 
microscopic in amount and persists no longer than 36 hours. Bleeding pro- 
duced by transection of snnall arteries in the kidney has occasionally been 
observed. These hemorrhages usually halt spontaneously. 

More serious accidents also occur. Occasionally, the needle has been 
known to penetrate the pelvis of the kidney. This is discovered by the reflux 
of urine through the biopsy needle or from recovery of mucosal tissue in the 
biopsy specimen. Although this would seem to be a serious event, it is 
usually uncomplicated lonless the urinary tract is obstructed. Occasionally, 
the hilar vessels have been opened by the percutaneous needle. Bleeding fronn 
this source is potentially serious, especially if the renal vein is involved. 
Although bleeding from the hilar vessels is more serious than from others, 
hemorrhage from any source may be alarming. Hemorrhage has on occasion 
required operative intervention for control. The incidence of severe hemor- 
rhage requiring some form of treatment (transfusion or surgery) has been 
surprisingly low. 

Immediate or delayed pain occurs in a small number of patients. The 
pain may be either colicky or it may be constant and localized in the flank. 
Rarely is it severe. 

The size or age of the patient also does not seem to limit the procedure. 
At least one patient of 450 pounds has been biopsied successfully. The per- 
cutaneous renal biopsy has been carried out successfully at every age from 
one year into the seventh decade. It is probable that at both ends of this 
age range, the risks are increased. 

In addition to certain reservations in the selection of patients with 
hypertension, bleeding dyscrasias, et cetera, a careful study of the x-ray 
filnns of the kidney will probably prevent a small number of accidents that 
would occur because the kidney is in an abnormal location. A single kidney 
would seem to be sufficient cause for avoiding a biopsy. Also, it appears 
to be sound practice to carry out the procedure in the hospital and to keep 
the patient under observation and at bed rest for 48 hours subsequent to the 

Unless a patient is in uremia or in the nephrotic syndrome, the pri- 
mary renal diseases are remarkably asymptomatic. Obviously, a patient 
with lupus nephritis may have other stigmata of systemic lupus erythema- 
tosus; a patient with the Kim melstiel- Wilson lesion will probably have overt 
diabetes, but a large number — perhaps the majority of patients with prinnary 
renal disease who are accustomed to receive close medical attention — are 
discovered by routine urinalysis. This appears to be less true of children 
than of adults. 

In a patient without signs or symptoms, there are relatively few abnor- 
malities of the urine which help in formulating a specific diagnosis. Unfor- 
tunately, the list of such findings is short. 

Red cell casts and hemoglobin casts have long been interpreted as 
indicating an acute glome ruliti 8. Albuminuriagreater than 5gm. per24hours 

Medical News Letter, Vol. 33, No. 11 13 

usually indicates one of the diseases capable of producing the nephrotic 
syndrome. This is also true of birefringent fat in cells and casts. Glitter 
cells are often associated with pyelonephritis. Papillae in the urine are a 
good, although rare, sign of acute necrotizing papillitis. Bacteria in a fresh 
clean urine suggest chronic pyelonephritis. Hemosiderin in cells suggests 
a form of renal siderosis. 

Other laboratory findings in an asymptomatic patient are also of assis- 
tance. A high blood globulin points strongly to amyloid or systemic lupus; 
a low albumin suggests an early nephrotic syndrome and usually — although 
not invariably — limits the diagnosis to those diseases which produce this 
syndrome. The finding of L. E, cells suggests lupus. Longstanding chronic 
infection suggests amyloid. Most laboratory findings only suggest a renal 
disease; usually they do not establish a specific diagnosis. 

Even patients with marked renal insufficiency and uremia and patients 
with the nephrotic syndrome may have little to suggest a specific diagnosis. 
Any one of a large number of disease entities may produce the nephrotic syn- 
drome. A list of diseases producing the nephrotic syndrome should include 
lipid nephrosis, chronic glomerulonephritis, systemic lupus, diabetes mel- 
litus, polyarteritis nodosa, renal vein thrombosis, amyloid disease, and 
certain drugs and toxins. The nephrotic syndrome has been reported to occur 
with other entities, but this occurs rarely and the possibility always exists 
that a primary renal disease of another sort has been overlooked. The pure 
lipid nephrosis, for instance, niay be diagnosable only by the electron micro- 
scope. The renal biopsy is undoubtedly a justifiable diagnostic tool, although 
it has not yet reached full maturity in clinical practice. For most patients, 
the risks do not appear to be excessive. An added caution must be exercised 
in malignant hypertension, but even here, after careful appraisal of this 
added risk, the biopsy may still be justified. The experience of the operator 
would appear to modify some of the risk. 

The biopsy has often added to the confusion surrounding a given case 
because it maybe uninterpretable or because it provides an unfamiliar com- 
plex of findings. This result is becoming less common with increasing ex-» 
perience. Even when the histology of the kidney is not diagnostic, it may 
suggest something of clinical value about the nature of the disease process, 
such as the presence of vascular disease, focal nephritis, or tubular disease 
of unidentified nature. The use of the electron microscope has considerably 
extended the range of the percutaneous biopsy. It is unfortunate that the cost 
and complexity of this instrunnent have confined it to certain centers. It 
should be remiembered also that a number of technical failures will occur and 
the sampling error may be large. 

Despite these real problems, the percutaneous renal biopsy is often the 
only way of establishing a diagnosis and makes its greatest contribution in the 
appraisal of the asymptomatic patient with proteinuria and an abnormal uri- 
nary sediment. (Arnold, J. D. , Spargo, B. , Clinical Use of the Percutaneous 
Renal Biopsy: Circulation, XIX: 609-620, April 1959) 

14 Medical News Letter, Vol. 33, No. 11 

Management of the Bladder 

in Traumatic Paraplegia 

The need for assiduous bladder care from the very beginning of para- 
plegia is of the utmost importance, and its unremitting continuance through- 
out the paraplegic's life should be emphasized. Many complications may 
be averted and rehabilitation of the patient greatly accelerated. 

A patient with a recent cord injury should be on continuous bladder 
drainage with a self-retaining Foley catheter (5 cc. bag). It is' important 
that the catheter be no larger than a Fr. 18 because of the danger of urethral 
fistula from pressure necrosis. In the event of urethral sepsis, drainage 
can more easily seep out aroxind a small catheter. 

The catheter requires careful attention. Syringe irrigation with ster- 
ile water or saline should be done daily to insure patency and keep bladder 
infection nninimal. The procedure is done as aseptically as possible and the 
patient can be taught eventually to irrigate Ms own bladder. Tidal drainage 
has been advocated by others, but does not appear to have any special advan- 
tages. The catheter should be changed every 10 to 14 days even if there is 
no evidence of incrustations. 

A bladder training prog rami can be instituted while the patient is still 
in bed as soon as cystometric studies indicate that bladder activity has be- 
come reflex in type or vesical tone has been regained. The catheter is 
clamped for 1-1/2 hours at a time except at night. At the end of each of 
these periods, the clamp is released and the patient strains as in normal 
voiding. The fluid intake is adjusted so that no fluid is taken between the 
hours of 7:00 p. m. and 7;00 a. m. , and one glass of water (250 cc. ) is ingested 
hourly during the other 12 hours. After the patient is able to remain dry for 
a week without leakage arotind the catheter between emptyings, the interval 
should be increased to 2 hours. After this, the interval is increased to 
2-1/2 hours, and then to 3 hours. Accumulation of more than 400 cc. in the 
bladder, however, should not be allowed to occur. 

The catheter may be removed when the patient can stay dry for 3 hours 
without leaking around the catheter. It is advisable to postpone removal of 
the catheter until the patient is at least semiannbulatory and able to strain 
more efficiently. 

After removal of the catheter, the patient is instructed to void on 
schedule and regulate fluid intake as before. Urination is usually done in a 
sitting position. Some patients find thay can empty their bladder best by 
doing a "push-up, " that is, by abdominal straining and suprapubic manual 
compression. After a time, they may find that they have some trigger area 
in the abdomen or thigh which, if touched or stroked, precipitates reflex 
micturition. The patient with a nonreflex bladder obviously cannot develop 
a conditioned voiding reflex and will have to rely on abdominal straining and 
Crede pressure to assure effective emptying. Residual urine is checked fre- 
quently during the first few weeks after catheter removal. 


Medical News Letter, Vol. 33, No. 11 15 

The amount of residual urine is dependent on a balance between the 
expulsive force of urination (detrusor contraction, abdominal straining, and 
nnanual compression) and the resistance at the bladder neck. If a high resid- 
ual urine (more than 100 cc. ) is present in spite of efficient expulsive forces, 
there must be^ellhtfj^^a mechanical or spastic obstruction at the vesical neck 
which should be relieved. 

Transurethral resection producing a widening of the vesical neck has 
been of great benefit to many patients with large amounts of residual urine 
regardless of bladder type and even in the absence of demonstrable bladder 
neck obstruction. The procedure is generally not performed earlier that 
8 months after injury. Removal of a ring of tissue or even a small resection 
of the anterior lip reduces the resistance encountered by the detrusor so that 
residual urine decreases. 

Pudendal neurectomy has been considered as the best treatment for 
spastic sphincteric obstruction. Other procedures, such as intrathecal in- 
jection of alcohol, sacral rhizotomy, and cordectomy have also been recom- 
mended. Some of the procedures have the disadvantage of converting an 
upper motor to a lower motor neuron lesion and, therefore, abolish reflex 
detrusor contraction and generally weaken detrusor tone. 

Somie workers in the past have advocated treating the urinary infection 
in paraplegia only when clinical evidence of sepsis ensued. Routine med- 
ication was not advised because of the fear of drug resistance. Consequently, 
chronic infection has remained uncontrolled in a large number of paraplegics 
and probably is the main factor responsible for the observed high incidence 
of chronic pyelonephritis and renal insufficiency. 

With the present availability of a wide variety of broad spectrum anti- 
biotics and other efficacious chemotherapeutic agents, their prolonged admin- 
istration in reduced dosage is probably advisable in much the same way that 
similar extended therapy has become acceptable in the treatment of rheumatic 

The incidence of calculus formation in the paraplegic individual is dis- 
tressingly high, especially during the first 2 years after injury. As a con- 
sequence of lack of stress and strain upon the bony skeleton, large amounts 
of calcium and phosphorus are liberated from the bones and are swept into 
the urine where excessive excretions lead to stone formation. 

Therapy is aimed to forestall calculus formation by preventing exces- 
sive super saturation of the urine with calcium and phosphorus. It may be 
accomplished by diluting the concentrations of the iniplicated crystalloids, 
by reducing their total excretions, or by increasing their solubilities in the 
urine. The concentrations of stone-forming salts in the urine can be reduced 
most effectively by increasing urinary volume with forced fluids. A paraplegic 
patient should drink a minimum of 3 liters of water a day. The excretions of 
calcium and phosphorus in the urine may be decreased by dietary restrictions 
and the reduction of bone demineralization. Ingestion of milk and its products 
should be limited. 

16 Medical News Letter, Vol. 33, No. 11 

Vesicoureteral reflux is probably the major factor in the spread of 
infection to the kidneys among paraplegics. Unless satisfactory bladder 
drainage can be assured, reflux is also invariably followed by hydronephro- 
sis. The latter, however, can occur with no demonstrable vesico-ureteral 

A patient exhibiting vesicoureteral reflux should be carefully observed 
and intravenous pyelograms and cyatograms performed every 3 months. 
Bladder training is contraindicated, and at the first evidence of hydrone- 
phrosis, a catheter should be inserted and straight bladder drainage insti- 
tuted. Hydronephrosis with no associated vesicoureteral reflux is also 
treated by dependent continuous bladder drainage. 

The paraplegic patient must be followed with the utmost vigilance for 
the rest of his life. It should be impressed upon him that his future well- 
being and chance of survival depend to a large extent upon his willingness 
to cooperate fully in the follow-up examinations. Intravenous pyelography 
and cystography should be made every year and residual urine measured 
every 6 months even when all appears to be going well. It should also be 
borne in mind that dangerous renal lesions may develop insidiously and a 
bladder that empties well is no guarantee for the permanency of good renal 
function. (Morales, P. A. , Hotchkiss, R. S. , Management of the Bladder 
in Traumatic Paraplegia: Arch. Phys. Med., 40: 141-148, April 1959) 

ifc ;{c ;^ ^ 3|< :{$ 

Treatnnent of Parosteal Osteoma of Bone 

Parosteal osteoma occurs in both benign and malignant forms, with 
the malignant form a predonninant feature of the disease. In 1951, the 
authors reported 16 cases as a new entity, histologically similar to myositis 
ossificans, but with a more intimate relationship to bone and having a graver 
prognosis. Jaffe and Selin, as well as Coley and Higinbotham, have briefly 
described a type of osteogenic sarcoma which has the features of the disease 
described in this report. More recently, Dwinnell, Dahlin, and Ghormley 
and Dahlin have written on this subject, preferring to designate the disease 
entity as "parosteal osteogenic sarcoma, " thus emphasizing the growth 
potential or subsequent malignant changes noted in many of the cases studied. 
These authors reported 15 cases. 

The relationship of the malignant phase of parosteal osteoma to a pre- 
ceding benign growth appears to be an unusually intimate one. The initial 
lesion is most frequently a benign proliferation of ossifying fibrous tissue 
which results in a rounded bony nnass projecting from the shaft of a long 
bone at, or near, the metaphyseal region. There is usually no base or ped- 
icle of orderly bone growth, formed by the underlying normal bone and capped 

Medical News Letter, Vol. 33, No. 11 17 

by cartilaginous tissue as is often seen in osteochondromas or exostoses. 
Instead, the ossifying mass, by contiguity, eventually invades adjacent 
cortical and cancellous tissues at one or more points. The process also 
extends in an outward direction into the soft parts, often involving the mus- 
cles with or without a periosteal pseudo-encapsulating membrane. Islands 
of cartilage may be found within the ossifying mass intermingled with more 
direct ossification from fibrous tissue. The cartilage does not form a sep- 
arate zone of superimposed tissue, such as occurs in osteochondromas. 
Therefore, it would appear that the benign phase of the tumor is character- 
ized by ossifying fibrous tissue arising in the region of the periosteum of 
long bones — femur, tibia, fibula, humerus, ulna, and radius. The tumor 
shows a tendency to progressive growth and ultimate malignant change. 
The malignant phase of the process is akin in its histology to sclerosing 
osteogenic or fibrosarcoma. The evolution from benign to malignant forms 
often appears to be a gradual process extending over a number of years. The 
number of 5 -year cures (60%) obtained in this group by resection or amputa- 
tion is unusually high as compared with rates of survival among nnany other 
forms of bone sarcoma. 

Parosteal osteomas occur most often in the first four decades of life; 
between the ages of 8 and 40 years. In 10 of 22 cases reported, the lesions 
were found on the posterior surface of the lower femur, bulging into the 
region of the popliteal space. Similar growths were observed about the upper 
femur, the upper and lower portions of the humerus, the upper ulna and radius, 
the upper fibula, and lower tibial regions. There were 12 females and 10 males 
among the patients studied. 

A swelling or mass and local pain or tenderness were the outstanding 
clinical features. The duration of symptoms extended over a period of weeks 
to years. Ten patients had noticed a mass for one year or more. One patient 
had noticed an increasing enlargement of the lower thigh for 7 years. At tinnies, 
progressive increase in the size of the mass was the only symptom. Apparently, 
trauma had not played a significant role in the development of these lesions, 
although in 3 patients it led to the discovery of the mass. In one patient, irrad- 
iation for skin disease preceded the bone lesion by 32 years. 

On examination, a mass of bony hardness is felt which is firmly attached 
to the adjacent bone. The tumor extends into the soft parts and may involve 
muscle. The periphery of the bony mass is usually smooth in contour, although 
in a few cases it was found to be infiltrating. The slow growth of the tumor, its 
discrete character, and the normal appearance of the overlying soft parts sug- 
gest a relatively benign growth. 

There are no systemic features, such as the leucocytosis and fever fre- 
quently seen in rapidly growing sarcoma of bone. 

In the roentgenogram, the tumor is seen as a parosteal mass of ossify- 
ing tissue which involves the ends of long bones, but has its most prominent 
manifestations in the overlying soft parts. The tumor, in its early , phases , 

18 Medical News Letter, Vol. 33, No. 11 

is visible as a dense irregular or rounded mass of new bone which is firmly- 
attached to the cortex along a portion of its broad base, but is separated for 
most of its circumference from the underlying skeletal structures. There 
maybe several discrete smaller masses. This is particularly true if reciir- 
rence has followed a previous operation. The underlying bone forms an ir^ 
regular sclerosis suggesting a platform for the new growth through widening 
of the cortex and with some periosteal reaction. In late cases, the densly 
ossifying mass seems to envelop the underlying bone. In recurrent tumors 
following surgical excision, often after prolonged intervals, active and prom- 
inent medullary involvement may be seen with obvious roentgenographic 
features of malignant change. In view of the density of the osseous shadow 
and its size in primary cases, there is surprisingly little destruction or 
reaction in the adjacent bone. The diagnostic features of prinr^ary lesions 
are the density of the osseous mass, well delineated margins along one or 
more aspects of the periphery, and the occasional independent or discrete 
secondary osseous growths. 

A review of 16 cases previously reported by the authors with the addi- 
tion of 6 new cases emphasizes the fact that paro steal osteonnas are poten- 
tially malignant lesions. At the initial operation, the specinnen often may 
be chiseled away or resected with a portion of the underlying bone and may 
fail to show histologically nialignant features on adequate examination. 

Of the 22 cases studied, the original lesion appeared to be benign in 

14 patients. Subsequent surgery, necessary for recrudescence of disease, 
revealed the tumor as benign in only 2 cases at the second operation. The 
tissue removed in the only or final operation was considered malignant in 

15 patients, benign but cellular in 3 specimens, and typically benign in 
4 instances. 

The history of slow growth, the circumscribed character of the neo- 
plasm at operation, and the benign histology of the excised mass may give 
the surgeon a false sense of security. The temptation is to consider these 
growths as atypical examples of myositis ossificans. The subsequent course 
of the disease, however, compels reevaluation. The irregular osseous sur- 
face of the cortex at the operative site, showing renewed or continued activity, 
presages the development of masses of irregular bone which penetrate into 
the adjacent soft parts. Eventually, the recurrent mass tends to surround 
and invade the bone in frankly sarcomatous fashion. From the standpoint of 
prognosis, 4 of the 22 cases were considered indeterminate. 

The absolute 5 -year survival rate proved to be 63. 6%, while the adjust- 
ed 5-year survival rate was 60% in the patients treated. This latter rate does 
not include the indeterminate cases nor the patients who lived 5 years and 
subsequently died of their disease. Of those patients surviving 5 years or 
more without disease, the final operation was amputation in 6 cases and ex- 
cision or resection in 5 cases. Two of the latter patients received x-ray 
therapy in addition to local removal of the tumor. 

Medical News Letter, Vol. 33, No. 11 19 

Of 18 determinate cases, 11 patients are living and well for 5 or 
more years {60%). In 8 of the 13 patients, the disease recurred after local 
excision or resection, resulting in amputation. Five of the 8 patients died 
of their disease, while 3 are living and well for 5 years or more. Three 
primary amputees are 5-year survivals without disease. 

Bold ablative surgery by resection or amputation is necessary to cure 
parosteal osteoma in the majority of cases. If complete resection in a rel- 
atively inactive lesion can be accomplished, cure should resulti There is 
no place for temporizing surgical excisions. If there is any question about 
adequate en bloc resection, then amputation is indicated. When pathologic 
changes show frank sarcoma, amputation is indicated at once. Recurrent cases 
with or without malignant nnanife stations, are best treated by amputation. 

Care should be exercised not to confuse parosteal osteoma with 
osteogenic sarcoma situated predomiinantly in the periosteal zone of long 
bone structure. The differential diagnosis also includes atypical myositis 
ossificans, certain osetochondromas, and osteomas. (Copeland, M. M. , 
Geschickter, C. F. , The Treatment of Parosteal Osteoma of Bone: Surg. 
Gynec. & Obst. , 108:537-548, May 1959) 

Digitalis Intoxication 

This article re emphasizes the varied clinical pictures produced by 
digitalis intoxication in the hope that morbidity ajid mortality of this iatro- 
genic disease maybe reduced. 

The clinical records and electrocardiograms of those patients dis- 
charged from the City of Memphis Hospitals with the diagnosis of digitalis 
intoxication in the years, 1940 through the first quarter of 1957, have been 
reviewed. The criteria used in confirnning the diagnosis of digitalis intoxi- 
cation in this review consisted of symptoms or electrocardiographic signs 
of digitalis intoxication which disappeared on omission of digitalis. In most 
cases, there was a definite history of ingestion or administration of exces- 
sive amounts of digitalis. One hundred and forty-eight cases were found 
to conform to these criteria. 

Seventy-five cases were males and 73 were females. The racial inci- 
dence of intoxication with digitalis corresponded to the admissions from each 
racial group to this hospital. The youngest patient was 6 years old, the old- 
est, 96 years old. Approximately one -third of the cases occurred in patients 
in the seventh decade of life (31%); about one-fifth each were patients in their 
sixth and eighth decades (19.6 and 18.3%, respectively). The diagnosis was 
infrequently made (11 instances) in persons less than 40 years of age. The 
etiologic diagnoses of the heart disease under treatment conformed to the 
general incidence of these diagnoses at this institution. 

20 Medical News Letter, Vol. 33, No. 11 

The majority of patients in this series were in rather severe conges- 
tive failure; this is best shown by the fact that 117 patients (79%) were func- 
tionally in classes III and IV according to the New York Heart Association's 

Anorexia, nausea, and cardiac irregularities were almost equally 
frequent'as the initial manifestation of digitalis intoxication in this series. 
The next most common sign of intoxication proved to be an increase in the 
severity of the congestive failure which improved when the digitalis prepara- 
tion was withheld. The duration of intoxication prior to clinical recognition 
varied tremendously, i, e. , from a few hours to several months. Not infre- 
quently, the presence of other signs or symptoms of intoxication was required 
before a correct diagnosis could be made. In 7 patients (4. 7%), one or more 
subjective manifestations were the sole changes produced by intoxication; in 
these cases, the diagnosis was clear only when the symptoms disappeared on 
withholding digitalis. Electrocardiographic changes alone indicated the pres- 
ence of digitalis intoxication in 37 instances (25%). The great majority of 
patients, however, presented both signs and symptoms (104, or 70,3%). The 
symptoms and signs (including types of arrhythmia encountered) are presented 
in Tables. It is to be remembered that two or nnore arrhythmias (or conduc- 
tion defects) frequently occurred in the same patient during the course of 

Digitalis leaf was by far the most frequent cause of toxicity in this 
series. Next most frequently producing intoxication was digitoxin, either 
alone or in combination with lanatoside C. Other preparations were found to 
be responsible only occasionally. It was found that an average maintenance 
dose of digitalis leaf (gr. 1, 28 daily) frequently produced intoxication. When 
first manifestations of intoxication were correlated with the preparation used, 
it was found that 51% of the patients receiving purified preparations first suf- 
fered symptoms as compared with 68% of those receiving digitalis leaf, i.e. , 
the patients receiving leaf more frequently experienced anorexia, nausea, or 
vomiting before the appearance of arrhythnnias than did the patients on puri- 
fied glycosides. Electrocardiographic changes or increase in failure was 
the initial manifestation of toxicity in 49% of patients on purified glycosides 
and in 32% of patients on leaf. Unless digitalis intoxication was recognized 
soon after its onset, there was no difference in the incidence of subjective 
and objective signs in cases taking leaf and in those taking purified glycosides. 
An attempt was made to ascertain whether there was any reason other than 
individual sensitivity for patients to become intoxicated on an "average" main- 
tenance dose of digitalis. Uremia was found to be no more frequent in patients 
who became intoxicated on average doses of digitalis than in patients who 
received doses larger than average. The weight distribution of patients who 
became intoxicated on average doses of digitalis did not differ from the weight 
distribution of patients who becanne intoxicated on doses greater than average. 
The frequent use of mercurials, with or without marked weight loss, occurred 
with equal frequency in both groups. 

Medical News Letter, Vol, 33, No. 11 21 

In this series, the maximal duration of toxicity was 1 6 days in a patient 
whose arrhythmia, produced by digitoxin, was treated with quinidine. For 
the last 4 years, potassium chloride, either intravenously in a slow drip 
(ZO to 40 mEq. /hr. ) or by mouth (4. to 8. gm. daily), has been routinely 
used as treatment. No case of intoxication persisted more than 6 days on 
this regimen; most arrhythmias disappeared in from hours to Z days. Pro- 
cainamide was occasionally used (orally or intravenously) with success. 

Digitalis intoxication was thought to be the cause of death in 6 patients 
of this series. Autopsies were performed on 5 of these 6 patients, no ana- 
tomic cause for death could be demonstrated in any of the 5. 

Digitalis intoxication occurs on any dosage. It is apparent that digi- 
talis, like insulin, must be carefully fitted to the needs of each patient. Only 
by cautious trial and error with careful clinical and electrocardiographic 
observation of the patient can the digitalizing and maintenance doses be cor- 
rectly determined in the individual, (von Capeller, D. , Copeland, G. D, , 
Stem, T.N. , Digitalis Intoxication - A Clinical Report of 148 Cases: Ann. 
Int. Med., 50:869-876, April 1959) 

sfc s4£ ^ sfe sic sJc 

Staphylococcal Pneumonia - Clinical 
Evaluation of Forty Cases 

This is a report of further clinical investigation of staphylococcal 
pneumonia. Forty cases were diagnosed and treated in the U. S. Naval 
Hospital, St. Albans, N. Y. , during a ZO -month interval. Historically, they 
may be categorized as hospital and nonhospital acquired, with further des- 
cription as follows: 

(a) Complication of preexisting major disease, 

(b) postinfluenzal, (c) postoperative, and 
(d) occurrence in hospital personnel 

Diagnostic features of history, physical findings and the patient's 
clinical appearance were utilized together with roentgenologic and bacterio- 
logic findings to institute early decisive therapy. Emphasis was placed on 
personal examination of sputum smears, cultures and chest roentgenograms, 
and consultation with a mobilized "pneumonia team. " 

Early in this experience, it became evident that there were radiologic 
characteristics peculiar to staphylococcal pneumonia of high reliability in 
leading to diagnosis. 

Analysis of antibiotic sensitivities revealed most of the encountered 
organisms to be resistant to the sulfonamides, tetracyclines, streptomycin, 
and penicillin. The best therapeutic results were obtained with ristocetin 
(26 cases). Vigorous supportive therapy included tracheostomy (21 cases). 
Gamma globulin was administered to 16 patients as adjunctive therapy. 

22 Medical News Letter, Vol. 33, No. 11 

During the course of their pneunnonia, 8 patients died, 6 of whom had 
other lethal primary disease (metastatic carcinoma, lymphoma, etc. ). 
Twelve patients had a significant fail in hemoglobin and hematocrit during 
their infections, 3 of whom became icteric; an additional 2 had icterus 
without change in hemoglobin. Twenty patients had a leiokocyte count below 
12, 000 mm. at the time of diagnosis. Pulmonary coinplications encountered 
were pneumothorax, empyema, lung abscess, and tension cysts. Only 2 
patients had significant respiratory disability after recovery. 

Awareness of the manifestations and gravity of staphylococcal pneu- 
monia, with attention to early diagnosis and decisive therapy, is emphasized 
as essential for the successful management of this disease. (L. R. Schuniacher, 
LT MC USN, J. R. Coates, LT MC USN, R. C. Sowell, LT MC USN, and 
G. L. Calvy CAPT MC USN, Department of Medicine, U. S. Naval Hospital, 
St. Albans, N. Y. : Clin. Research, 7_: ^67, April 1959) 

JLetter to the Surgeon General 

The Surgeon General has extracted the following paragraphs from a 
letter recently received from a Rear Adnniral USN. It points out the impor- 
tance of taking the necessary time and trouble to explain to a patient — flag 
rank or enlisted — what you are doing, why you are doing it, and the meaning 
of your findings. This is good MEDICINE — most of us practice it, more of 
us should: 

"Without detracting in any way from the thoroughness of the physical 
examinations which we, in the Navy, are given annually, I must say 
that I have never before been so completely satisfied in my own mind 
concerning the thoroughness of an examiination. Additionally, Commander 
Sanborn spent a considerable amount of tinne explaining to me why they 
were doing what they were doing, what they were looking for and — in 
some cases — the meaning of what they found. I realize, of course, that 
it would be impractical for all officers in the Navy, even the most senior, 
to be put through such a series of examinations on a routine basis. How- 
ever, Bart, I sincerely hope that you and your people will meet with 
every success in any attempt which you nriight make to expand the cover- 
age given by this group at Pensacola. 

To sum up then, I do want to express to you my appreciation for your 
personal interest in my case and to let you know what I think of the 
medical group in whose hands you placed me. " 

Medical News Letter, Vol. 33, No. 11 23 

Medical Symposiums for Fiscal Year 1960 

Three Medical Symposiums (MWMS) (formerly SWMS) will be conducted 
at the Field Command, Armed Forces Special Weapons Project, Sandia Base, 
Albuquerque, N. M. , for Fiscal Year I960 as follows: 

MWMS - 6 14-18 September 1959 

MWMS - 7 16-20 November 1959 

MWMS - 8 14-18 March I960 

The Navy has been allotted a quota of ten spaces for each course; Seven 
(7) spaces will be reserved for active duty career Medical officers; three (3) 
spaces will be reserved for inactive Reserve Medical officers. 

TOP SECRET security clearance is required on all candidates approved 
for attendance. 

Officers desiring to attend this course should submit a written request 
to the Bureau via their Commanding Officer. Requests must be received in 
the Bureau of Medicine and Surgery by the following dates for each course as 

MWMS - 6 27 July 1959 

MWMS - 7 28 September 1959 

MWMS - 8 . 25 January I960 

All requests must indicate that a security clearance of TOP SECRET 
has been granted to the officer requesting attendance. 

Successful candidates will be issued Temporary Additional Duty travel 
and per diem orders from this Bureau's training funds. (ProfDiv, BuMed) 

Environn^ental Sanitation Courses for Medical 
Service Warrant Officers 

Applications are invited from Medical Service Warrant officers interested 
in assignment to duty under instruction in Environmental Sanitation at the Univ- 
ersity of California, Berkeley, Calif. This 5 -month course, commencing in 
January I960, consists of full-time academic training in general sanitation, 
medical statistics, vector control, venereal disease control, bacteriology, 
and communicable diseases. Successful completion leads to designation and 
assignment as Environmental Sanitation Officer, 

Applications must be submitted to the Chief, Bureau of Medicine and Surg- 
ery via the chain of command, to reach the Bureau no later than 15 August 1959. 
The following information is required in each application: (1) Resume of aca- 
demic backgroiind; (2) Obligated Service Agreement (as set forth in paragraph 
8. a. of BuMed Instruction 1520. 12) 

It is highly desirable that a copy of all transcripts of formal college train- 
ing be submitted with the application unless these have been furnj-shed previous- 
ly to the Bureau. (MSC Div, BuMed) 

24 Medical News Letter, Vol. 33, No. 11 

Medical Intelligence Reports 
( Med-3820TT ) 

The attention of all Medical officers, particularly those serving at 
sea or on foreign shore, is invited to the requirements of Article 23-124, 
Manual of the Medical Department. Compliance with this article is of great 
importance to the Navy Medical Departnrient and the Navy as a whole, 

(ProfDiv, BuMed) 

:Jc ^ ^ % * * 


RADM Clyde B. Camerer MC USN (Ret) 12 May 1959 

CAPT Thomas M. Arrasmith MC USN (Ret) 4 March 1959 

CAPT Walter P. Dey MC USN (Ret) 14 April 1959 

CAPT Franklin F. Murdock MC USN (Ret) 3 April 1959 

CAPT Wilfred M. Peberdy MC USN (Ret) 13 February 1959 

CAPT Albert G. Wenzell MC USN (Ret) 4 April 1959 

LCDR Charles H. Shifflette MSC USN (Ret) IS April 1959 

L.T John E. Dumas MSC USN (Ret) 26 March 1959 

ENS Lois M. Harkness NC USN (Ret) 13 February 1959 

ENS Mary F. Spencer NC USN (Ret) 14 April 1959 

WO Donald R. Haguewood HC USN (Ret) 27 April 1959 

jfe A sfe rfc >5c A 

From the Note Book 

1. Atthe closing sessionof the Annual Aerospace Medical Association Meeting, 
the following Navy Medical officers were honored: CAPT C. P. Phoebus MC 
USN received the Theodore C. Lyster Award for outstanding achievement in 
the general field of Aviation Medicine. CAPT E. L. Beckman MC USN, Naval 
Aviator, was presented the Eric Liljencrantz Award for the best paper on 
basic research in the problem of acceleration. CAPT R. B. Lautzenheiser 
MC USN, CAPT F.K. Smith MC USN, and CAPT J. T. Smith MC USN were 
all elected Fellows of the Association for their outstanding contributions in 
the field of Aviation Medicine. CAPT O. W. Chenault MC USN was elected 
First Vice President of the Association for Fiscal Year I960. He will be 
President Elect in 1961 and President in 1962. (TIO, BuMed) 

2. LCDR Eggert Petersen, Coordinator of Psychological Training in the 
Royal Danish Navy, has begun a two -month orientation training visit to the 
United States to obtain first hand information on the U. S. Navy's psychological 

Medical News Letter, Vol. 33, No. 11 25 

program. He will become familiar with all phases of the Navy's preventive 
psychiatry program. Particular emphasis will be placed on aspects of the 
program pertaining to the selection and training of personnel. (TIO, BuMed) 

3. JLCDR J. E. Szakacs MC USN presented a paper entitled "Pathologic 
Implication of Catechol Amines" at the Seminar of the Surgical Physiology 
Section, Walter Reed Army Institute of Research, May 7, 1959. The data 
presented included the physiological effects and pathologic changes of con- 
trolled amounts of injected norepinephrine in the treatment of shock from the 
recent studies made by the speakerj by CDR R. M. Dimmette MC USN and 
CDR E. C. Cowart, Jr. MC USN, all attached to the U. S. Naval Medical School, 
NNMC, Bethesda, Md. (NavMedSchl, NNMC). 

4. Under certain provisions of the law, con:imissioned officers in the U. S. 
Navy and Naval Reserve may be transferred to other U. S. military services. 
The Department of Defense Reorganization Act of 1958 made provision where- 
by the President of the United States may transfer any commissioned officer 
with his consent from the Army, Navy, Air Force, or Marine Corps, and 
appoint him in any other Armed Force. Bureau of Naval Personnel instruc- 
tions 1120. 30 and 1120. 31 spell out the regulations in detail. (NavNews 95-59) 

5. An "almost explosive extension" of disease prevention and medical care 
has taken place in the Soviet Union, but the quality of service falls short of 
that foiind in the United States. "The Report of the U. S. Public Health Mission 
to the Union of Soviet Socialist Republics" (PHS Pub. No. 649) contains the find- 
ings of a Mission of five doctors who visited the Soviet Union late in 1957 under 
the exchange program approved by the two countries in 1956, (PHS, HEW) 

6. This article discusses the results of therapy in 102 patients with chronic 
lymphocytic leukemia, and in 118 patients with chronic granulocytic leukemia 
who were treated predominantly with radioactive phosphorus. The 5 -year sur- 
vival was 51% for chronic lymphocytic leukemia and only 12. 5% for chronic 
granulocytic leukemia. (Ann. Int. Med. , April 1959; E. H. Reinhard, M. D., 
C, L. Neely, M. D. , D. M. Samples, M. D, ) 

7. This article discusses a little known form of sarcoidosis in which poly- 
arthritis is a conspicuous or dominant clinical finding. There is reason to 
believe that the joint disease is a manifestation of sarcoidosis and that it 
occurs more frequently than has been recognized. (New England J. Med. , 
23 April 1959; L. Sokoloff, M. D. , J.J. Bunim, M. D. ) 

8. This report, based on 62 cases of endometrial carcinoma in which treat- 
ment consisted of the Wertheim hysterectomy, is presented as a critical study 
of the many factors underlying the management of this problem by a radical 
surgical approach. (Surg. Gynec. & Obst, , May 1959; L. Parsons, M. D. , 

F. Cesare, M. D. ) 



Medical News Letter, Vol. 33, No. 11 



Dental Officer Strength Down - 
Dental Procedures Up 

During calendar year 1958, the strength of Navy Dental Corps officers 
declined from the calendar year 1957 average of 1799 to 1677, or 6.8%. 
However, the 7,474,929 dental procedures performed during 1958 represent- 
ed a decline of only 4. 6% below the 1957 total of 7, 838, 063. The average 
number of procedures performed per Dental officer in 1958 (4457) increased 
2. 3% over the 1957 average (4357). 

:{c 9$: :^ ^ :jc :{: 

Nonadherence to Repair Contract 

A contract was negotiated with the Midwest Dental Manufacturing 
Company early this year for the repair of higher speed belt driven hand- 
pieces manufactured by that company. A letter, dated February 10, 1959, 
from Chief, Bureau of Medicine and Surgery to All Ships and Stations Having 
Dental Personnel, included a copy of the contract and pertinent infornnation 
for its implennentation. The effective date of the contract was March 1, 1959. 

Information received from the manufacturer indicates that some activi- 
ties are returning handpieces for repair without adhering to the provisions of 
the contract. This action results in unnecessary correspondence and undue 
delays in the return of the repaired handpieces. Additional copies of the 
contract may be obtained from: Dental Materiel Officer, Field Branch, 
Bureau of Medicine and Surgery, Sands and Pearl Streets, Brooklyn 1,N. Y. 


>^ »}; i|c ^ ^ ;{: 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md, , giving full name, rank, corps, am.d old and new 

Medical News Letter, Vol. 33, No. 11 27 


Medical Department Correspondence Courses 

Purpose and Mission. 

The correspondence course program of the Bureau of Medicine and 
Surgery is administered by the U. S. Naval Medical School, Bethesda, Md.' 
It is designed for training Medical Department personnel in medical-military 
ftinctions and responsibilities of the Navy Medical Service. The objective of 
the program is to enable Naval personnel, active or inactive, to enhance 
their knowledge and proficiency in duties of rank or rate through independent 
study during off-duty hours. 

The training program provides Naval Reserve officers with additional 
means of earning nondisability retirement and promotion point credit; it gives 
Regular and Reserve Navy officer personnel an alternate method by which 
they may wholly or in part qualify for promotion. Evidence of satisfactory 
completion of specified correspondence courses will gain for the enrollee 
exemption from specific written examinations. Regular Navy enlisted per- 
sonnel may use this method of training to qualify for advancement. Inactive 
Naval Reserve enlisted personnel may earn nondisability retirement points 
and become better qualified to perform their medical-military duties. 

In general, study materials consist of official Naval regulations, and 
reference and training manuals. When specific textbooks are required, they 
are purchased by the Navy and supplied to the enrollee; these materials are 
supplemented by guides composed of special instructions and assignments. 
Because the assignnnents are study aids, questions are answered with the 
textbook open. A course may include from one to sixteen assignments. 

Within the limits of medical application, the battery of available 
courses presents a wide choice for the enrollee. The courses include not 
only those related to specific duties of personnel, but those which will also 
broaden their knowledge of medical-military naval subjects and keep them 
abreast of new developments. 

The Naval Medical School welcomes new participants in the Corres- 
pondence Training Program. Because the courses are currently provided 
for Regular and Reserve officers and enlisted personnel of the Medical 
Department of the Armed Forces, officers of the U. S. Public Health Service, 
and Foreign Armed Forces Medical Department personnel, an optinnal dis- 
tribution of naval training is thus attained. This total participation increases 
the availability of training material and promotes an excellent exchange of 
Medical Department training information and aids. This may give rise to 
a new source of technical assistance for the benefit and welfare of all Armed 
Forces in the preparation of future training programs. 

28 Medical News Letter, Vol. 33, No. 11 


Medical Department correspondence courses are available at no cost 
to Regular and Reserve officers, enlisted personnel of the Arnaed Forces, 
officers of the U. S. Public Health Service, and Foreign Armed Forces 
Medical Department personnel. 

Application Instructions 

The form, Application for Enrollment in Officer Correspondence Course, 
NavPers 992 {Rev 2/58 or later revision) should be completed and forward;ed 
to the Commanding Officer, U.S. Naval Medical School, National Naval Med- 
ical Center, Bethesda 14, Md. The appropriate change in the "To" line in. 
Box J of the application form should be made. These forms can be obtained 
from your Comnnanding Officer or from the respective District Headquarters. 

Completed applications will be forwarded as follows: 

1. If on active duty: via your Commanding Officer. 

2. If on inactive duty and not in a training program under the cogni- 
zance of the Chief of Naval Air Reserve Training (CNART): via your 
Naval District Commandant. 

3. If on inactive duty and in a training program under the cognizance 
of CNART: via the Commanding Officer of NAS or NARTU having res- 
ponsibility for the training program. 

4. If on inactive duty and residing in a foreign country: via (1} the 
local Naval Attache or Force Commander, if any, and (2) the command 
maintaining your service record (usually your home District Commandant). 

5. Foreign Armed Forces Medical Department Personnel: in accord- 
ance with paragraph 348d, OpNavInst 4950. IB. 

CAUTION 1 Do not send applications for enrollment in Medical Depart- 
nient correspondence courses to the U.S. Naval Correspondence Course 
Center, Naval Supply Depot, Scotia 2, N. Y. Such procedure delays the pro- 
cessing of the application by several weeks. Send to that address only 
applications for enrollment in courses administered by that Center, 

Multiple Enrollment 

Medical personnel maybe enrolled in more than one Medical Department 
correspondence course at one time . 


Title and NavPers Number Assignments Points 

Atomic Medicine 8 24 

NavPers 10701 -A 

Aviation Medicine Practice 6 18 

NavPers 10912-A 

Medical News Letter, Vol. 33, No. 11 


Title and NavPers Number 



Blood Transfusion, Methods and Procedures 
NavPers 10998-1 



Combat and Field Medicine Practice 
NavPers 10706-A 


Control of Commtmicable Diseases in Man 
NavPers 10772 


Hospital Food Service Management 
NavPers 10767 


Hospital Personnel Administration 
NavPers 10734 


Insect and Rodent Control 
NavPers 10705-A 

Legal Medicine 
NavPers 10766 


Low Temperature Sanitation and 
Cold Weather Medicine 
NavPers 10997-A 

Manual of the Medical Department, Part I 
NavPers 10708-2 


Manual of the Medical Departnnent, Part II 
NavPers 10709-2 


Medical Department Orientation 
NavPers 10953-A 

Medical Service in Joint Oversea Operations 
NavPers 10769 

Pharmacy and Materia Medica 
NavPers 10999-1 


Physical Medicine in General Practice 
NavPers 10735 



Medical News Letter, Vol. 33, No. 11 

Title and NavPers Number 

Kadioisotopes in Medicine 
NavPers 10773 

Submarine Medicine Practice 
NavPers 10707-A 

Treatment of Chemical Warfare Casualties 
NavPers 10765 

Tropical Medicine in the Field 
NavPers 10995 

Assignments Points 

7 21 

6 18 



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UccupatwTmi nleaicme 

Common Errors in the Diagnosis of Plumb ism 

Today, few diseases are as easy to diagnose as industrially induced 
plumbism. The area of contact is not elusive, the symptoms of 99% of all 
cases are well defined and the laboratory results, when procured by efficient 
techniques, are generally conclusive. Little of this can be said of most occu- 
pational diseases. 

As a preface to any reniarks on the diagnosis of plunabism, it appears 
logical to accept this viewpoint, that whatever the present attitude may be 
towards the value of diagnosis in general medicine, it will be reflected in 
occupational medicine. That there has been a deterioration in the art of 
diagnosis is obvious; due, no doubt, to the profession's overwhelming inter- 
est in the spectacular. Down the hallway of medicine as one passes hatracks, 
a diagnostic hat is indifferently tossed without looking to see if it has landed 
on the right peg. Haste is made to a room on the door of which is emblazoned in 
gold letters, T-H-E-R-A-P-Y. Therein is to be found the drama of medicine, 
likely as not being televised to a palpitating public. Also, therein is found the 
means to cure a patient before a diagnosis is correctly established. 

Still to be heard or read is the statement that plumbism is a protean 
disease. The tense of the verb should be changed to read "was a protean 
disease. " Factors which once permitted months or years of exposure to undue 
concentrations of lead dust or fumes no longer exist. It would be extremely 
rare in the experience of any physician today to see an industrially induced 

Medical News Letter, Vol. 33, No. 11 31 

case of plumbism characterized, by the neuromuscular syndrome or enceph- 
alitis. It is, therefore, erroneous to assign to modern day lead intoxication 
the bizarre findings perpetuated in the literature. 

Errors in the diagnosis of plumbism arise out of an inadequate history, 
insufficient knowledge of occupational environment, and reliance upon laboifa- 
tories whose experience and efficiency are not known. A common source of 
error arises out of faulty collection of materials as well as the interpreta- 
tion of reports submitted by the laboratory. The figures presented by the 
report must be evaluated in relation to the history of exposure and the clin^ 
ical picture. The author's conclusion is that plumbism is not difficult to 
diagnose if these common errors are avoided. (Johnstone, E. T. , Common 
Errors in the Diagnosis of Plumbism: Indust. Med., 28: 126-133, March 

A sji: :^ ^ :ic :{: 

Evaluation of Blood Lead Analyses 

The laboratory offers a number of tests and analyses which are useful 
in the diagnosis and control of lead poisoning. Each has its advantages and 
disadvantages. The stippled cell count, the basophilic aggregation test, and 
the urinary coproporphyrin determinations are simple and rapid, but they are 
not specific for lead poisoning because they indicate pathologic reaction in 
the body which may be due to other morbid states as well as to lead poison- 
ing. Urinary and blood lead determinations possess the virtue of specificity 
for lead; however, the analytical procedures are tin^e consuming and require 
considerable care and skill on the part of the analyst. 

Urinary lead values show relatively large day to day variations, al- 
though they correlate well with lead intake. Because of this correlation and 
the ease of obtaining samples, urinary lead values are widely used as a 
biologic test for the monitoring of lead exposures to indicate the need for 
further clinical and environmental controls. The analysis of urine for lead 
is somewhat, but not significantly, less difficult than the similar analysis 
of blood. In general, the concentration of lead in blood is considered to be 
more closely related to the clinical diagnosis of lead poisoning than are 
urinary lead values. That other clinical signs and symptoms of lead intox- 
ication may exist when there is no abnorinal elevation of the blood lead and 
that such signs and symptoms may be absent when the blood lead concentra- 
tions are quite high is a recognized enigma. Because of this, the ultimate 
diagnosis of lead poisoning depends on the skill of the physician in assessing 
the significance of the combination of laboratory results along with signs and 
symptoms in each case. Nonetheless, the determination of lead in blood 
remains one of the most valuable tests for lead poisoning. 

32 Medical News Letter, Vol. 33, No. 11 

Concentrations above 0. 08 milligram (mg) lead per 100 milliliters 
(n:il) of whole blood are believed to be abnormal and indicative of unusual 
absorption of lead. Values of 0. 05 or less nng/100 ml were reported in 75% 
of normal subjects. 

Recent work favors the expression of milligrams or micrograms of 
lead per 100 grams (gm) of whole blood rather than the expression per 100 
milliliters as previously used. Blood lead concentrations in excess of 0. 06 
to 0. 08 mg/100 gm are unquestionably indicative of a greater than normal 
absorption of lead. Values as high as 0. 12 nng/100 gm are not uncommon 
among some industrial workers and others having an abnormal exposure to 
lead. The diagnostic significsuice of elevated levels of lead in blood and 
their correlation with clinical lead poisoning are not as well established as 
are the normal range of values. 

The lead in the blood is concentrated for the most part in or on the 
red blood cells. The proportion of lead in the serum increases with the total 
lead concentration in the blood. 

The actual chemical form in which lead is transported in the blood has 
not been definitely established. Various suggestions are colloidal dilead 
phosphate, lead diphosphoglycerate, a lead albuminate, or other phosphate 
or organic lead complexes. 

In the spring of 1958, the Occupational Health Program, U. S. Public 
Health Service, agreed to coordinate a project for the voluntary cooperative 
evaluation of analyses for lead in blood. A plan was drawn up for the sub- 
mission to cooperating laboratories of several sets of blood samples with 
known amounts of added lead to be prepared by the Occupational Health 
Program laboratories for analysis. The principal objectives of the project 
were stated: (l)to secure a statistical appraisal of the general competence 
in this analytical diagnostic service, and (2) to provide participating labor- 
atories with a controlled self -appraisal of their techniques of blood lead 
dete rm inati on a . 

Subsequently, the health officer of each State was requested to desig- 
nate and to secure the participation of some clinical and industrial hygiene 
laboratories having responsibility for blood lead analyses in his State. The 
inclusion of every possible laboratory was neither anticipated nor intended 
as the project was conceived to evaluate the general level of analytic per- 
formance. It follows that should the study reveal serious inadequacies, fur- 
ther action should be taken by those laboratories to inrjprove their methods 
and techniques. The first set of samples was prepared and mailed in dupli- 
cate to the 50 participating laboratories. The methods of analyses to be used 
by these laboratories were not specified. Each laboratory was asked to 
determine the lead in the samples by whatever procedure they would nor- 
mally use. 

Although the final results are not known, it is felt that this project to 
evaluate the analyses of lead in blood will prove to be very worthwhile-and 

Medical News Letter, Vol. 33, No. 11 33 

will have a beneficial effect on the accuracy and reliability of blood lead ana- 
lyses in general. Such an evaluation is a project which any laboratory or 
group of laboratories may carry out for their own benefit and information. 
Indeed, every laboratory doing determinations of blood lead values should 
appraise its techniques in this manner at reasonably frequent intervals. 
Such appraisal should certainly include the entire procedure on actual blood 
samples and not be content with analyses of aqueous solutions of known lead 
concentrations. The importance and the difficulties of blood lead determina- 
tions require such vigilance to prevent backsliding into unreliable or erron- 
eous work. (Byers, D. H. , An Evaluation of Blood Lead Analyses, Indust. 
Med., 2£: 117-lZl, March 1959) 

3p i^ ^ 3{c ?{c :{£ 

Cadmium Poisoning 

Recently, a few cases of acute cadmiurn poisoning were reported to 
the Bureau of Medicine and Surgery. These cases involved personnel en- 
gaged in oxy-acetylene flanne cutting of cadmium coated steel torpedo war- 
heads which had been junked. In view of the foregoing, it seems appropriate 
to review briefly the subject of cadmium poisoning. 

Acute Cadmium Poisoning 

In 1924, Legge reported 3 cases of cadmium poisoning, one of them 
fatal, in men in a paint factory where ingots of cadmium were melted 
during a period of 3 hours in a poorly ventilated room. All of the 3 meii 
complained of dryness of the throat, headache, and nausea. The urine 
was colored brown. A necropsy on the man who died showed hyperemia 
of the bronchi, gastrointestinal tract, and kidneys. In 1942, Nasatir 
reported a fatal case. Death occurred on the fifth day after exposure to 
cadmium fume caused by burning off with an oxy-acetylene flanne, deposits 
of metal containing a high percentage of cadmium. The symptonns consist- 
ed of a feeling of constriction of the chest, increasing dyspnea, and cough 
which became much worse before death. 

Symptoms and Signs . In 1944, Spolyar and others wrote an extensive 
report on cases of cadmium poisoning resulting from flanging operations 
of cadmium -plated pipe. The resulting exposure to cadmium-oxide fume 
led to 5 cases, including one death. On the basis of the 59 cases reported 
up to that date, the mortality rate of industrial cadmium poisoning appears 
to be 15%. In 1948, Johnstone reported the case of a young Mexican labor- 
er who was sent to the hospital following the use of an oxy-acetylene torch 
on the inside walls of a furnace in which cadniium residues had been re- 
covered from scrap metal. The patient was extremely ill with severe 
dyspnea and exhaustion, and gave a history of headache, cougli, and pain 

34 Medical News Letter, Vol. 33, No. 11 

in the chest. The temperature rose to 104° F. , the pulse to 140 and the 
respiratory rate to 50. Patchy signs appeared in the chest and broncho- 
pneumonia was revealed by x-rays. Cyanosis and increasing respiratory 
distress preceded death. At necropsy, the lungs showed confluent bron- 

Mass Poisoning by Cadmium-Oxide Fume. In 1944, Ross described 
mass poisoning due to cadmium-oxide fume affecting Z3 workers. Finely 
divided cadmium dust from a cadmium recovery chamber became ignited 
owing to redhot cigarette ash carelessly dropped by one of the workers. 
In a few minutes, the cadmium dust became incandescent and emitted 
clouds of cadmium -oxide fume. The victims complained of irritation of 
the eyes, headache, vertigo, dryness of the throat, cough, constriction 
of the chest, and weakness of the legs. Three hours later, a set of de- 
layed effects was observed. These included shivering, sweating, nausea, 
epigastric pain, and dyspnea. No case was fatal. 

Chronic Cadmium Poisoning 

Chronic cadmium poisoning leads to loss of weight, cough, and dysp- 
nea, together with gross pulmonary emphysema. The lungs may be so 
severely affected that they push the liver and spleen down, rendering 
them easily palpable in the abdomen. There is staining of the teeth in 
the form of a golden-yellow ring and a raised erythrocyte sedimentation 
rate. Eaader, in 1951, suggested that the symptom complex of a running 
nose with soreness and prickling should be called cadmium rhinitis be- 
cause it occurs so frequently. The sense of smell becomes impaired or 
abolished — cadmium anosmia — and in such cases there is usually atrophy 
of the nasal mucosa. 

An Unusual Proteinuria . There is an unusual protein in the urine. 
Friberg, in 1951, investigated the proteinuria in a group of 43 men who 
had been employed from 9 to 34 years in an alkaline accumulator factory 
in Sweden. In the urine as tested with 25% nitric acid, protein was de- 
tected in 28 men; as tested with trichloracetic acid, it was detected in 
35 men. The proteinuria was not demonstrable by the boiling test nor 
by picric acid. By electrophoretic analyses, the protein was shown to 
differ from ordinary urinary protein and to have a molecular weight 
between 20, 000 and 30, 000 Friberg suggests that these patients excrete 
in the urine cadmium linked with protein. 

Morbid Anatomy and Histology . In a man aged 39 who had been ex- 
posed to cadmium dust for 8 years in an accumulator factory, Baader, 
in 1951, found at necropsy emaciation, chronic rhinitis with atrophy of 
the nasal mucosa, chrome vesicular emphysema, purulent bronchitis, 
and interstitial pneumonia. There was also nephrosis. Severe dilatation 
of the stomach was found together with several areas of segmental cyl- 
indrical distention and elongation, 8 to 12 centimeters long, in the jejununn. 

Medical News Letterj Vol. 33, No. 11 35 

Histological examination showed nuclear changes in the ganglion cells of 
the walls of the trachea and bronchi, together with similar changes in 
the ganglion cells of the plexuses of Auerbach and Meissner. No changes 
were found in any other nerve cells. Friberg, in 1951, exposed E5 rabbits 
to cadmium dust for Z to 3 hours daily for a period of 7 to 9 months. Pro- 
teinuria was found in most of the animals after 6 months' exposure; the 
protein was of the same type as that found in the men employed in the 
accumulator factory. At necropsy, chronic rhinitis was found in 16 cases 
and tracheitis in 20. Chronic bronchitis and emphysema were present in 
all of the animals and nephrosis was found in the majority. 

Preventive Treatment 

When cadnnium is heated, dangerous quantities of cadnnium oxide are 
formed and volatilized. Therefore, in the smelting of cadmium ores, the 
welding of alloys and the firing of cadmiunn -plated metal, precautions 
should be taken to remove all fumes by means of adequate exhaust ven- 
tilation. It has been suggested that all cadmium -coated metal should bear 
a warning label. While this nneasure is effective for large pieces, it is 
somewhat difficult to insure that sn:iall objects so coated are labelled 
(Fairhall, 1946). Symptomatic treatment is directed specifically against 
pneumonia when it occurs. {Excerpt from test. The Diseases of Occupa- 
tions, by Donald Hunter, M. D. , F. R. C. P. ) 

^ 2^ !fC Sf£ yjfi 9jC 

Heat Stress in Tropical Climates 

During World War II, environmental physiologists conducted tests in 
laboratory hot rooms and in the field to determine the effect of heat on young 
men at work and at rest. Such studies led to improved fabrics and designs 
for hot weather clothing, established the importance of water and salt in pre- 
venting heat exhaustion, and provided indices for evaluating the combined 
effect of environnaental and metabolic heat on military personnel. 

Heat casualties still occur in unseasoned recruits undergoing summer 
training and in unacclimatized combat personnel rapidly moved to hot climates. 
There is also the problem of providing individual protection against enemy 
attack without imposing a further burden from climatic heat. These problems 
are discussed in this article. 

Classification of Hot Climates 

It is convenient to classify hot climates as "hot-dry" or "warm-humid. " 
Into the former class falls the desert climate characterized by high air tem- 
perature during the day, low humidity, intense solar radiation, a wide diurnal 
variation in temperature, and scanty precipitation. 

36 Medical News Letter, Vol. 33, No. 11 

"Warm-humid" or "warm -moist" climate is typically represented by 
the tropical rain forest areas lying within latitudes of 10 or 20 degrees from 
the Equator. It is characterized by: 

1. Air temperatures which are not excessive, the upper limit being 
90° to 95 F. , but the average relative humidity is 75% or higher. 

2. High moisture content of the atmosphere which reduces its trans- 
parency to solar radiation, thereby reducing solar heat loads on man. 
Direct solar heat is, therefore, less of a problem than in the desert. 

3. Little diurnal or seasonal variation in temperature and dew point. 

4. Heavy precipitation, usually varying with the seasons. 

5. Abundant vegetation providing ample shade and a favorable radiant 
en vi r onm ent. 

Heat Balance in Tropical Climates 

In tennperate climates, about 50% of the heat produced by the body is 
lost through radiation to cooler surfaces in the surroundings, about 25% is 
lost by convection to the cooler air, and about 25% by evaporation from the 
skin by insensible perspiration and from the upper respiratory tract. 

The human calorimeter at the Naval Medical Research Institute, 
National Naval Medical Center, Bethesda, Md. , provides a graphic picture 
of heat output from the human body during work or rest at different environ- 
nnental temperatures. Records show that, with increased heat production 
associated with work at moderate or high temperatures, the heat output rises 
from the resting level in an exponential manner, leveling off as the rate of 
heat loss finally balances the rate of heat production. Essentially, all of 
the extra heat is evaporative. 

On stopping work, the return of heat output to the resting level is also 
exponential, but the reverse of that seen during the rise. There is a lag in 
recovery because it takes time for heat stored in the body during work to be 

This emphasizes the importance of rest periods alternating with work. 
These periods must be of sufficient duration to allow recovery to occur. In 
hot environments, recovery will be slower than in cool environments because 
the nunnber of calories stored for a given work output will be greater, and 
dissipation of stored calories will be slower on return to rest. 

Although humidity has not been studied as a separate variable in these 
human calorimeter tests, one can predict that, for an air temperature of 
88 F. or above, the higher humidity will result in a greater extent of 
sweating over the body surface to provide enough evaporation to maintain 
heat balance. Although difficult to measure, the wetted area is greater in 
the humid heat of the tropics than in the same degree of dry heat in temper- 
ate zones. In other words, to maintain the same rate of evaporation in tropical 
heat, it is necessary that a greater proportion of the body surface be covered 
with sweat than in tern per ate climates. By the sanne token, sweating involving 

Medical News Letter, Vol. 33, No. 11 37 

100% of the body surface will occur at lower rates of work in the tropics than 
in less humid climates. Extensive and continuous sweating contributes to 
subject's sensations of discomfort and also to a high incidence of skin diseases. 

Some Military Problems Relating to Tropical Heat Stress 

Recruit Training . Heat stress imposed on trainees by a combination 
of hot weather and strenuous drills is a problem in peace time as well as 
during rapid mobilization for war. Nearly 200 deaths from heat stroke 
occurred in Army recruits at training centers within the United States during 
World War II. The individual chiefly at risk was an obese unseasoned recruit 
from a home in the north undergoing his first weeks of summer training in a 
southern state. 

Since World War 11, heat exhaustion and heat stroke have continued to 
be problems in recruit training. The extent of heat casualties is not ade- 
quately revealed by the number of cases admitted to the sick list, because 
for every admission there are approximately 10 cases of mild heat exhaustion 
treated in field dispensaries and returned to duty without being reported. 
Summer weather at the Marine Corps Recruit Depot, Parris Island, S. C. , is 
similar in nature to tropical climates. During the summer of 1952, occur- 
rence of heat casualties at Parris Island averaged over 50 per 10, 000 per 
week. Five recruits died of heat stroke in the 4-year period, 1950 - 1953, 

In 1954, a program for controlling heat casualties was introduced at 
Parris Island based on a policy of liberal water and salt intake, rational 
clothing practices, indoctrination of recruits and instructors in the elements 
of hot weather hygiene, and curtailment of strenuous activity during periods 
of high temperature and humidity. This brought about a striking reduction in 
incidence of heat casualties. On the basis of field studies conducted by the 
Bureau of Medicine and Surgery in 1954 - 1955, the program for controlling 
heat casualties was further modified in 1956. Since then, environmental heat 
stress has been expressed in terms of the Wet-Bulb Globe-Temperature Index 
of Yaglou (WBGT Index), which is derived from hourly readings of the natural 
wet bulb, black globe, and shade dry bulb temperatures weighted and added 
together as follows: 0. 7 WB (wet bulb) / 0, 2 GT (globe) / 0, 1 DB (dry bulb). 
Significant correlation was previously demonstrated between this index and 
evaporative weight loss in Marine Corps trainees undertaking various sum- 
mer exercises. 

At index levels of 85° F. or above, strenuous training activities are 
suspended for recruits in their first 3 weeks of training. More seasoned 
recruits continue regular drills xmtil the index reaches 88° F. , or above. 
Special conditioning platoons have been established for obese recruits and 
others substandard in physical fitness. A breaking-in period is required 
during the first week for eill recruits. Under current regulations, the outer 
shirt is discarded during hot weather drills. With the introduction of the 
modified regulations including the WBGT Index in 1956, incidence of heat 

38 Medical News Letter, Vol. 33, No. 11 

casualties showed a further significant reduction in incidence rate despite 
higher seasonal heat. Because the lower levels of heat stress apply only td 
recruits early in training, these gains have been accomplished at a lower 
cost in training time than under the former regulations. 

Whether the WBGT Index can be used for regulating training in hot-dry 
climates is a question which may be answered in tests scheduled for this 
summer at a Marine Corps base in the desert region of California. 

Lack of Acclimatization. Physical fitness alone does not provide pro- 
tection from heat. A highly trained combat unit of Marines was flown from 
northern California to Korea in August 1950 during the battle of the Pusan 
perimeter. Although in top physical condition, they suffered many heat 

A more recent experience occurred in July 1958 during the landing of 
four battalions of Marines in Lebanon. Effects of heat stress were obvious 
in these units. Fortunately, there was no hostile action ashore, otherwise 
the added heat load imposed by activity in combat would doubtless have in- 
creased the incidence of heat casualties. 

In February 1959 when Operation Banyan Tree was conducted by the 
Army, an opportunity arose to study the effect on physically fit troops of a; 
sudden change from a temperate to a tropical climate. A battle group of 
paratroopers from Fort Bragg, N. C. , was flown to Panama where they para- 
chuted to a drop zone near the Kio Hato and immediately engaged in strenuous 
combat exercises against a simulated aggressor. Measurements of body 
weight as well as urine analyses revealed significant degrees of dehydration 
and salt deficiency in the test subjects during the first 48 hours of the exer- 
cise. This was only a pilot study, but it indicates the need for further 
investigation of the physiological adjustments that occur during acclimati- 

Clothing and Protection Against Conventional and Nonconventional 
Weapons. In a tropical climate, any clothing whatever will interfere with 
evaporative cooling and thus impose an additional heat load. Hence, in the 
tropics, the least clothing is best from the standpoint of heat balance and 
conifort. Military personnel, however, are required to wear clothing not 
only for purposes of modesty, but also to provide protection from insects, 
from mechanical injury, and for camouflage. Studies in World War II led 
to the design of the present poplin tropical uniform which is readily per- 
meable to water vapor, but woven tightly enough to give necessary protec- 
tion from biting insects and skin abrasion. 

At present, however, the aim is to build into the uniform protection 
against various weapons as well. These would include high velocity shell 
fragments, thermal and ionizing radiation, and chemical and biological 

The Marine Corps is currently conducting studies on the effect of wear- 
ing body armor on the ability to maintain heat balance under tropical conditions. 

Medical News Letter, Vol. 33, No. 11 39 

Similar tests have already been conducted by the Army in the desert. Under 
hot-dry conditions, armor interferes only slightly with body cooling. It is 
too early to give results of tests in tropical environments, but one can prep 
dict that the problem will be nnore serious than in the desert because armor 
will reduce the wetted area of the body from which evaporation can occur. 

In case of radiological, chennical, and biological agents, the technical 
problems of providing protection without imposing an excessive heat load 
will be formidable. For the foot soldier fighting in hot climates, it would 
appear that some type of built-in cooling system will be required. 

Chronic Effects of Tropical Heat. It has been recognized since the 
time of Hippocrates that deterioration in physical and mental performance 
occurs during long sojourns in tropical climates. This was observed among 
American soldiers in New Guinea and other tropical areas during World 
War 11. Except for high incidence of skin diseases, however, it has not been 
possible to establish a physiological, nutritional, or biochemical basis for 
these changes or to establish that heat is the environmental factor chiefly 

It is now generally believed that psychological factors related to mono- 
tony and also the lack of recreation and normal social activity are more inm- 
portant factors than climate. 


1. Because of the high ambient vapor pressure in tropical climates, 
body cooling by evaporation of sweat is inefficient. This is the chief cause 
of tropical heat stress. 

2. Important effects of tropical heat are reduced exercise tolerance 
and depletion of body salt and water through excessive sweating. 

3. Through gradual exposure to heat and exercise, unacclimatized 
recruits can acquire heat tolerance without incurring high rates of heat 

4. Lack of accliniatization in physically fit combat units may jeopar- 
dize the success of missions conducted in hot climates. 

5. Technological developnnents are needed to resolve the present in- 
compatibility between tropical clothing designed for comfort and tropical 
combat uniforms designed for protection against enemy attack. 

(CDR D. Minard MC USN, Thermal Stress Branch) 

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Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget, 19 June 1958. 

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Medical News JLetter, Vol. 33, No. 11 


The U.S. Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
itenns of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original fornn. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

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